Back to Insights and Updates for ProvidersApril 2024

Updates to medical drug claims editing logic

All Tufts Health Plan Products  |  Harvard Pilgrim Health Care Commercial

As you likely know, Point32Health applies industry standard, compendia-supported claims editing logic to practitioner-administered drugs and biologicals — and the associated administration services under the medical benefit — based on indication, quantity, frequency, maximum units, and drug wastage.

We’re always listening to feedback from our provider network and looking for ways to make your experience more seamless and efficient when doing business with us. To that end, we’re updating this edit logic for Harvard Pilgrim Commercial products and all Tufts Health Plan products as of May 26, 2024 to remove edits related to age, lab tests, and drug therapy.

This update to claims editing logic will also apply for drugs associated with our OncoHealth medical management program. As a reminder, OncoHealth conducts medical review of chemotherapeutic protocols for Harvard Pilgrim Commercial members. For clinical and prior authorization criteria related to oncology medical drugs and protocols, refer to OncoHealth’s Harvard Pilgrim Prior Authorization Policies page.

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